&

‘The Digital Cardiologist’: How

Technology Is Changing the Paradigm
of Cardiology Training
Sebastian Vandermolena,b, Fabrizio Riccic,d,e,
C Anwar A Chahala,f,g,h, Claudio Capellii,
Khalid Barakata, Artur Fedorowskid,j,
Mark Westwoodb, Riyaz S Patela,i,
Steffen E Petersena,b, Sabina Gallinac,
Francesca Pugliesea,b, and Mohammed Y Khanjia,b,k*
From the a Barts Heart Centre, Barts Health NHS Trust, London, West Smithfield, EC1A 7BE, UK, b
NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary Univer-
sity of London, EC1A 7BE, UK, c Institute of Advanced Biomedical Technologies, Department of
Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University, Chieti, Italy, d Depart-
ment of Clinical Sciences, Lund University, Jan Waldenstr€ oms gata 35 205 02, Malm€ o, Sweden, e
f
Casa di Cura Villa Serena, Citt a Sant’Angelo, Pescara, Italy, Center for Inherited Cardiovascular
Diseases, WellSpan Health, Lancaster, PA, g Cardiac Electrophysiology, Cardiovascular Division,
Hospital of the University of Pennsylvania, Philadelphia, PA, h Department of Cardiovascular Medi-
cine, Mayo Clinic, Rochester, MN, i Institute of Cardiovascular Science, University College London
(London, UK)., j Department of Cardiology, Karolinska University Hospital, and Department of
Medicine, Karolinska Institute, Stockholm, Sweden and k Newham University Hospital. Glen Road,
Plaistow, Barts Health NHS Trust. London, UK.

Abstract: In the same way that the practice of cardiol-

ogy has evolved over the years, so too has the way car-
diology fellows in training (FITs) are trained.
Propelled by recent advances in technology—cata-
lyzed by COVID-19—and the requirement to adapt
age-old methods of both teaching and health care
delivery, many aspects, or ‘domains’, of learning have
changed. These include the environments in which
FITs work (outpatient clinics, ‘on-call’ inpatient ser-
vice) and procedures in which they need clinical com-
petency. Further advances in virtual reality are also
changing the way FITs learn and interact. The

Statements and Declarations - Competing interests and funding: SV, FR, CAAC, CC, KB, MW, RP, SP, SG,
FP, MK: noneAF: consultant and lecture fees from Medtronic Inc, Argenx BV and Finapres Medical Systems.
Curr Probl Cardiol 2022;47:101394
0146-2806/$ see front matter
https://doi.org/10.1016/j.cpcardiol.2022.101394

Curr Probl Cardiol, December 2022 1

 proliferation of technology into the cardiology curricu-
lum has led to some describing the need for FITs to
develop into ‘digital cardiologists’, namely those who
comfortably use digital tools to aid clinical practice,
teaching, and training whilst, at the same time, retain
the ability for human analysis and nuanced assessment
so important to patient-centred training and clinical
care. (Curr Probl Cardiol 2022;47:101394.)

Introduction

&
I
n the same way that the practice of cardiology has evolved over
the years, so too has the way cardiology fellows in training
(FITs) are trained. As technological advances have taken place,
changes have been made to every aspect of clinical training. Long-
accepted ways of working are constantly changing, catalyzed in part by
the COVID-19 pandemic.1,2 This change has been made possible by the
proliferation of internet-based tools, advanced imaging technologies and
the ever-increasing advances in computer and smartphone technology.3
Key learning environments, or domains, are recognized for FITs,
including outpatient clinics, inpatient service, procedural theatres and lec-
tures / conferences. Technology has affected all of these and has changed
how FITs now train and how they are likely to train in the future.
While new computer and smartphone technologies can affect all
domains as described above, 1 current paradigm shift is the convergence
of the real and virtual worlds. Initially a field reserved for computer sci-
ence enthusiasts in the 1980s, virtual reality has slowly been making
increasing footprints in real-world medical applications. Within cardiol-
ogy training, not only can it help train and teach clinicians, as will be
described below, but it is starting to facilitate comprehensive interactions
in completely virtual spaces, a theme that is likely to grow in the future.
A distinction is often made between virtual reality (where the user is
completely immersed in a virtual space), augmented reality (where vir-
tual elements are incorporated into a user’s real-world clinical space) and
mixed reality (where elements from both physical and virtual spaces
combine).4 Within cardiology, advances have been made in all 3 forms.
Given these changes, the emergence of the so-called ‘digital cardi-
ologist’ has been suggested to describe a cardiologist who uses digital
tools to aid clinical practice, teaching, training, and to improve patient
interaction. The key challenge going forward will be to keep digital

2 Curr Probl Cardiol, December 2022

technologies as a supportive tool, so as not to replace the human analysis
and nuanced assessment so important to clinical practice and training.

Learning ‘Domains’

1.
Outpatient Clinics

Outpatient clinics represent a valued learning environment for FITs as

they allow for the development and refinement of key clinical skills: his-
tory-taking, clinical examination, ordering of appropriate investigations,
and enacting management. Traditionally, they have served as a ‘safe’
space for FITs to practice clinical cardiology with stable patients with an
element of independence, but under the direct supervision of a consultant
(attending) who shares the clinic space.
Technological advancement has enabled the proliferation of so-called
‘telehealth’, and despite an initial reticence, virtual consultations have
become more common. The reduction in face-to-face (F2F) appointments
was already part of the National Health Service (NHS) Long Term Plan
published in 2019, targeting a reduction of visits by one-third over 5
years.5 Within cardiology, clinicians were already exploring the idea that
virtual clinics could be suitable, for example, for cardiac surgery follow-
up in the 2010s.6 Within electrophysiology, clinicians have been monitor-
ing heart rhythms remotely for many years; with implantable loop record-
ers, pacemakers and implantable defibrillators, teams have the
opportunity to contact patients in life-threatening arrhythmic events.
However, the key catalyst was provided by the COVID-19 pandemic, in
which hospitals were required to implement virtual appointments over a
matter of days as it quickly became the default method by which outpa-
tient appointments could be delivered.
Whilst several benefits of telehealth clinics have been described for
both patients and clinicians alike, from a training perspective, the 2 main
benefits include the flexibility to work from home (and thus help contrib-
ute to home/childcare duties in ways clinicians were not previously able
to do) and also the ability to be in more than 1 physical place at once. In
many regional health care configurations, numerous clinics take place
over various geographic locations, and thus conducting these clinics
remotely can help FITs save on travel time and money. The above is par-
ticularly pertinent given the efforts being made to increase inclusivity in

Curr Probl Cardiol, December 2022 3

cardiology training, such as the push to increase the number of female
trainees within the specialty as endorsed by the Women in Cardiology
(WIC) movement.
Despite the benefits, some have recognized some difficulties for FITs
with remote clinics. The outpatient clinic experience often allows imme-
diate diagnostic evaluation at the same time as the clinic consult, includ-
ing ECGs, chest X-rays, and echocardiograms. With virtual consults,
these are not immediately accessible and need to be separately ordered
after the consult, which can delay decision-making. Further, the use of
required technology can be difficult for both practitioners and patients
alike, especially for those who are elderly or who have sensory
impairment or language barriers. Thus, identifying patients who may be
more suited to F2F over virtual consultations is likely to be a key priority
to ensure that certain patients’ groups are not disadvantaged. In addition,
whilst some patients might prefer not travelling to the hospital, for some,
virtual appointments are unsatisfactory; for many patients, direct contact
with a physician is at least as important as the information relayed or the
investigations performed during the clinical consult.
Also lacking is the direct physical supervision of an attending consul-
tant. Whilst often FITs conduct clinics independently, the informal dis-
cussions about more complex patients are often absent, if not delayed,
especially if clinicians are in different geographic places. This delays
decision-making but also takes away from the mentorship-type learning
opportunity the clinic provides. Further, a more nuanced implication for
FITs of virtual clinics is a change to the so-called ‘community of
practice’. Initially described by Wenger in the 1990s,7 this explains that
people are accepted into a new community, in this case FITs into the
‘cardiology community’, by participating traditionally within a shared
physical space in simple, observed tasks and then progressing into more
complex ones as they become part of said community. The impact of
moving this into a virtual space is unclear.

Inpatient Service
Much of the learning for FITs comes from ‘on-the-job’ exposure when
‘on-call’. This often involves the assessment, investigation, and manage-
ment of unwell cardiac patients. The proliferation of smartphone-based
applications has opened access to a range of useful services, including
online medical textbooks and resources (such as UpToDate.com by Wol-
ters Kluwer) and clinical calculators (such as MDCalc by MD Aware
LLC). For FITs, having immediate access to the above can make

4 Curr Probl Cardiol, December 2022

diagnoses and treatment plans more appropriate whilst enabling learning
at the same time.
An extension to smartphone-based applications is the use of instant
messaging systems whilst on clinical duty, such as WhatsApp by What-
sApp Inc, and iMessage from Apple Inc This is often between junior
members of a team but can be useful between FITs and supervising con-
sultants. Clinical cardiology is often based on the interpretation of data,
commonly ECGs and echocardiographic pictures; being able to send
these to supervising consultants can aid decision making and contribute
to learning at the same time. Whilst most of these systems utilize end-to-
end encryption technology, regulations surrounding information gover-
nance and data protection, which are often country-specific, must be fol-
lowed.
Whilst physical examination remains a pivotal part of clinical assess-
ment, echocardiography has an important role. It can quickly identify
gross valvular or ventricular impairment. Traditionally, large echocardi-
ography machines were required, but more recently hand-held echocardi-
ography devices have been developed and are increasingly popular.
Some are stand-alone devices, some utilize FITs’ own smartphones.
These have good accuracy when compared to standard machines in terms
of assessment of ventricular systolic and valvular function,8 and mean
bedside echocardiography is available immediately and may even be
preferable at times, such as during the pandemics.9 FITs are thus able to
use this technology to acquire the initial images, and use file sharing soft-
ware on smartphones to share with supervising consultants.
Not only does this aid diagnostic capabilities but also gives FITs to the
chance to use the technique regularly, and in doing so, learn constantly. Of
note, in using hand-held devices for imaging, FITs must ensure that images
are labelled with patient-identifiable information and stored securely within
the hospital’s imaging archive so they can be reviewed at later dates. This
is important from a clinical governance point of view, but also from a train-
ing point of view. If images cannot be reviewed and feedback given, there
can only be limited learning involved in the process.

Procedural Competencies
One focus of general cardiology training is the development of a theo-
retical understanding and clinical competence in several procedures, with
requirements for proficiencies in non-invasive cardiac imaging techni-
ques, cardiac catheterization and pacemaker device implantation.

Curr Probl Cardiol, December 2022 5

 Traditionally, procedural training was based on both formal lecture-
based learning followed by apprentice-style practice. The phrase ‘see
one, do one, teach one’ was often applied to procedure-based specialties
and reflected a practice whereby students would attempt to perform a
medical procedure after seeing it being done a small number of times.
Understandably, patient safety was often a concern given how difficult it
is to perform a procedure safely in that context.
Simulation has provided an environment in which to learn, particularly
during the early phases of training. Not only do users have the ability to
practice technical skills and refine tactile assessment under expert tuition,
but simulation also allows for the ‘non-taught’ attributes of working in
the clinical environment to be practiced, including communication skills,
stress handling, human factor acknowledgement, and team working.10
The focus on this so-called ‘crisis resource management’ has been proven
to improve patient outcomes.11
Whilst echocardiography could formerly only be taught using real
patients or actors, the advent of simulators with haptic feedback has
enabled further training opportunities. HeartWorks by IntelligentUltra-
sound is one such device, which offers users the ability to practice scanning
on a fully interactive model and identify a wide range of cardiac patholo-
gies that junior trainees would rarely encounter in real clinical practice.
Simulation can also be extended to more complex cardiology work envi-
ronments such as the cardiac catheter laboratory. These immersive in-situ
simulations allow users from across the multi-disciplinary team to work
together on complex clinical cases and thereby ‘crash-land’ in practice
rather than in real life. The debriefing time is often the most important part
of immersive simulation, as it allows participants to reflect back on
observed technical and human factors displayed during the exercise.
These environments are particularly suited to FITs at the early stages
of their training, where they can learn at their own pace, without the
stresses and pressures of a real clinical environment. They are also of par-
ticular value at times when procedural volume is affected, such as during
the COVID-19 pandemic peaks. In the UK, some centers saw a 50%
reduction in cardiology admissions and 40% reduction in patients admit-
ted with myocardial infarction,12 thereby limiting the amount of hands-
on exposure trainees were able to experience. Despite the recognized ben-
efits, access to simulation-based training activities remains limited, with
under 20% FITs having the opportunity to learn via simulation in a recent
report of European trainees.13
Competency in the reporting of cardiac imaging is also a key part of
cardiovascular training, with much time spent by FITs on the reporting of

6 Curr Probl Cardiol, December 2022

cardiac computed tomography, cardiovascular magnetic resonance
(CMR) and ultrasound. Technological advances here are also beginning
to change the way scans are reported, particularly pertinent given the
>500% increase in CMR over the last 10 years.14 Machine learning pro-
grammes are starting to aid FITs in the analysis and interpretation of
scans. For example, replacing manual delineation of anatomical contours
with artificial intelligence tools has meant that assessment of ventricular
volumes on CMR can be quicker and less prone to inter-user variability.15
This can then allow FITs to analyze more scans in a given time period,
thus increasing exposure to cases. The skill of being able to check for
quality and adjust machine learning contours or analysis should still be a
skill that is learnt.

Multi-disciplinary Meetings / Lectures / Workshops

Attending multi-disciplinary meetings is also an essential part of train-
ing for FITs. With the coming together of experts from across a range of
disciplines, it has long been a place whereby difficult cases and topics are
discussed, providing the FIT with the nuanced art of weighing up the
risks and benefits of certain treatments and interventions. These have
increasingly been conducted remotely, even using virtual reality in some
centers to recreate the experience of being ‘in the room’.9 These have
also allowed FITs to attend when not physically in a certain place, again
increasing availability to good learning environments for FITs who may
need to cover large geographic areas as part of their service provision.
Didactic teaching has also long been a steadfast method within cardiol-
ogy curricula. Technology has made the international cardiology world
smaller. Again, catalyzed by demands for virtual interaction in the con-
text of COVID-19, not only large-scale cardiology conferences were con-
verted to online web-based platforms, but also regular teaching across
institutions. In the UK, FITs brought together global experts for regular
teaching on key cardiology concepts.16 This has implications not only for
FITs in countries in which there is a comprehensive cardiology curricu-
lum, but also to FITs from across the world, especially low-middle
income health care settings, who otherwise may not get this breadth of
expertise in their training.17 On the other hand, networking and social
interactions are lacking with virtual conferences and potential barriers to
collaboration and learning through personal interactions with others.
Platforms such as Microsoft Teams have also gained popularity, and
not only allow video-based discussions, but facilitate efficient sharing of
documents and allow for lectures to be recorded and watched at any time.

Curr Probl Cardiol, December 2022 7

 Further, virtual and augmented reality is playing an ever-increasing
role. From a teaching point of view, 3D visualization and simulation can
help reinforce understandings of key concepts. In the UK, the UCL Insti-
tute of Cardiovascular Science and Great Ormond Street hospital have
recently adopted virtual reality (VR) into their curriculum; a novel VR
platform, VheaRts, is designed to explore high-definition, patient-specific
models of congenital heart disease. The platform has been used for teach-
ing cardiac anatomy to medical students (Figs 1 and 2).18 Similarly, in
the USA, VR is being increasingly used to teach cardiac anatomy.19
Beyond anatomy, this technology has also been rolled out to help teach
CPR.20 Given the level of interactivity involved, commentators have
described how VR facilitates the ‘gamification’ of learning, whereby
numerous game principles, such as teamwork, task completion, and
points collection are incorporated into the learning process. Its popularity
can be seen by the increasing body of evidence surrounding the use of
VR in the clinical training workplace.21
VR also has a role in the training and planning of specific cardiology
procedures which helps FITs engage with the precise anatomical
details and procedural techniques involved. In terms of coronary

FIG 1. Students using virtual reality headsets to aid cardiac anatomy teaching (photo acknowl-
edgements: Prof Andrew Cook and Endrit Pajaziti, UCL).

8 Curr Probl Cardiol, December 2022

Curr Probl Cardiol, December 2022

FIG 2. Students using hand consoles to help manoeuvre around 3D cardiac structures whilst emersed within the virtual reality space (photo acknowledge-
ments: Prof Andrew Cook and Endrit Pajaziti, UCL).
9
FIG 3. (Central illustration). Summary of different domains relating to cardiology training and
the potential impact of technology on each domain (Created using Biorender.com).

intervention, operators have used wearable headsets projecting CT recon-

structions of occluded vessels onto the headset glass. This helps operators
follow guidewire trajectories without changing the field of view.22 In
terms of structural interventions, VR has been found to improve anatomi-
cal understanding and surgical preparedness, improved understanding of
spatial relationships and allowed operators to simulate surgical strate-
gies.23 It can also help predict and prevent recognized complications of
specific procedures, such as heart block following TAVI procedures.24
Also exciting within the structural space is the expanding role of remote
proctoring using augmented reality. In one example, operators were
equipped with a smart-glass headset consisting of 2 HD cameras, a torch,
microphone and speaker, and external visor. Successful proctoring for a
complex transcatheter aortic valve replacement was conducted via a
remote expert who was able to view both the procedural field and fluoro-
scopic / hemodynamic views.25 Within electrophysiology, operators are
starting to combine electromagnetic maps with 3D projections to create
real-time anatomic maps of patient-specific arrhythmia substrate and
catheter locations.26
Beyond the use of virtual reality to aid physical and simulated data
fusion, with the proliferation of so-called ‘avatars’ living within the

10 Curr Probl Cardiol, December 2022

‘metaverse’, completely virtual identities can be created in completely
virtual environments. Within cardiology training specifically, there is
thus the possibility for virtual cardiology consults by virtual clinicians
(representing real physicians) with virtual patients (representing real
patients and incorporating real clinical data).27 The implications for this
on cardiology training remain to be seen with potential for clinical gover-
nance and privacy breaches, but it opens the door for new potential future
routes of health care delivery.

Electronic Portfolios
In the UK, an electronic portfolio (ePortfolios) to document achieve-
ment and education was introduced in 2005 and has been updated to fol-
low the updates in the cardiology curriculum, the latest being in 2016.
Before this, assessment of FITs was less formal, consisting of more spo-
radic interactions with trainers with no central control over the type of
assessment required for each stage of training.28
In its current form, the ePortfolio allows for trainees to systematically
chart progress through work-based assessments, procedural competency
reports and patient and staff feedback questionnaires. Similar tools exist
in other countries.29
Beyond training, Internet-based platforms that allow the listing of pub-
lished papers and achievements, such as ResearchGate (ResearchGate
GmbH), Publons (Clarivate Analytics) and ORCID.org (Open Researcher
and Contributor ID), allow for increased sharing of knowledge and poten-
tially increased collaboration amongst research groups which continues
throughout a medical career.

Future Perspectives
Since restrictions, imposed during the COVID-19 outbreak, have been
recently lifted, many have made efforts to return to pre-pandemic levels
of activity as quickly as possible. Some of the changes forced on us by
the pandemic have allowed not only more flexibility, but also a more
comprehensive adoption of technological tools and devices at large in our
interactions with patients. This has enabled age-old practices to be
revised and in many situations delivered in a better way. Thus, whilst the
pandemic may have served as the catalyst, it is likely that many of the
changes to the ways of working will continue going forward.
That remote clinics have so far been demonstrated to be as safe as F2F
clinics, suggests that a combination of remote and F2F working may be

Curr Probl Cardiol, December 2022 11

an option for many patient groups.30 Further, as technology continues to
improve in terms of availability and cost, so too will its availability for
FITs. This is likely to be experienced with hand-held tools at the bedside,
such as ultrasound devices, as well as the proliferation of computer-based
systems, such as augmented reality software to aid planning for interven-
tional procedures. Within simulation, opportunities for FITs to engage in
virtual environments will continue to expand as the technologies become
more widely adopted. One area which may take longer to fully embrace
is that of the metaverse. Complete immersion in a virtual world is cer-
tainly exciting; in January 2022, medical students at Queen Mary Univer-
sity of London, participated in a surgery lecture within the metaverse,
with all students wearing virtual reality headsets.31 However, going for-
ward, conducting clinical consultations and reviews within a virtual space
raises many questions of security and ethics and adoption of its potential
from a clinical and training point of view will require further assessment
to ensure effective yet safe use.32

Conclusions
Technological advancements have impacted every sector within health
care delivery. Given the pivotal role cardiology FITs play in this, it has
also impacted how FITs train, whether in outpatient clinics, inpatient
wards or procedural theatres. The capabilities of modern technology are
constantly expanding the capabilities of what clinicians can do not just at
the physical bedside, but also increasingly within remote and virtual
workspaces too.
Numerous human-to-human interactions take place within medicine;
between peers, senior colleagues, teachers and patients. Therefore, as our
understanding and adoption of these new technologies increase, so too
must our appreciation of their nuanced role alongside, not in place of,
clinicians throughout the various sectors of health care delivery.

REFERENCES
1. Chong JH, Chahal A, Ricci F, et al. The transformation of cardiology training in
response to the COVID-19 pandemic: enhancing current and future standards to
deliver optimal patient care. Can J Cardiol 2021;37:519–22.
2. Chong JH, Chahal A, Gupta A et al. COVID-19 and the digitalization of cardiovascu-
lar training and education a review of guiding themes for equitable and effective
post-graduate telelearning. Front Cardiovasc. Med 8:666119. Doi 10:3389/
fcvm.2021.666119

12 Curr Probl Cardiol, December 2022

 3. Chong JH, Ricci F, Petersen SE, et al. Cardiology training using technology. Eur
Heart J 2021;42:1453–5.
4. Silva JNA, Southworth M, Raptis C, et al. Emerging applications of virtual reality in
cardiovascular medicine. JACC Basic TranslSci 2018;3:420–30.
5. National Health Service. The NHS long term plan. Health document 2019.
6. Athanosopoulos LV, Athanasiou T. Are virtual clinics an applicable model for service
improvement in cardiac surgery? Eur J Cardiothorac Surg 2017;51:201–2.
7. Wenger E. How we learn. Communities of practice. The social fabric of a learning
organization. Health care Forum Journal 1996;39:20–6.
8. Andersen GN, Haugen BO, Salvesen O, et al. Feasibility and reliability of point-of-
care pocket-sized echocardiography. Eur J Echocardiogr 2011;12:665–70.
9. Khanji MY, Ricci F, Patel RS, et al. Special Article The role of hand-held ultra-
sound for cardiopulmonary assessment during a pandemic. Prog Cardiovasc Dis
2020;63:690–5.
10. Joshi A, Wragg A. Simulator training in interventional cardiology. Interv Cardiol
2016;11:70–3.
11. Boet S, Bould MD, Fung L, et al. Transfer of learning and patient outcome in simulated
crisis resource management; a systematic review. Can J Anaesth 2014;61:571–82.
12. Fersia O, Bryant S, Nicholson R, et al. The impact of the COVID-19 pandemic on
cardiology services. Open Heart 2020;7:1–6.
13. Czerwinska-Jelonkiewicz K, Montero S, Baneras J. The voice of young cardiologists.
Eur Heart J 2020;41:2723–5.
14. Keenan NG, Captur G, McCann GP et al. Regional variation in cardiovascular mag-
netic resonance service delivery across the UK. Heart 2021. Doi: 10.1136/heartjnl-
2020-318667
15. Ruijsink B, Puyol-Anton E, Oksuz I, et al. Fully automated, quality-controlled cardiac
analysis from CMR: validation and large-scale application to characterize cardiac
function. JACC Cardiovasc Imaging 2020;13:684–95.
16. COVID-19: education in the time of coronavirus.https://cardiovascularnews.com/
covid-19-education-in-the-time-of-coronavirus 2020
17. Haynes NA, Saint-Joy V, Swain J, et al. Implementation of a virtual international car-
diology curriculum to address the deficit of cardiovascular education in Haiti: a pilot
study. BMJ Open 2021;11:e048690.
18. Pajaziti E, Schievano S, Sauvage E, Cook A, Capelli C. Investigating the feasibility of
virtual reality (VR) for teaching cardiac morphology. Electronics 2021 6;10
(16):1889.
19. Wish-Baratz S, Gubatina AP, Enterline R, et al. A new supplement to gross anatomy
dissection: holoAnatomy. Med Educ 2019;53:522–3.
20. Balian S, McGovern SK, Abella BS, et al. Feasibility of an augmented reality cardio-
pulmonary resuscitation training system for health care providers. Heliyon 2019;5:
e02205.
21. Jung C, Wolff G, Wernly B, et al. Virtual and augmented reality in cardiovascular
care. J Am Coll Cardiol Img 2022;15:519–32.

Curr Probl Cardiol, December 2022 13

22. Opolski M, Debski A, Borucki B, et al. First-in-man computed tomography-guided
percutaneous revascularization of coronary chronic total occlusion using a wearable
computer: proof of concept. Can J Cardiol 2016;32. 829.e11-3.
23. Milano E, Kostolny M, Pajaziti E, et al. Enhanced 3D visualization for planning
biventricular repair of double outlet right ventricle: a pilot study on the advantages of
virtual reality. Eur H J (Digital Health) 2021;2:667–75.
24. Dowling C, Gooley R, McCormick L, et al. Patient-specific computer simulation to
predict conduction disturbance with current-generation self-expanding transcatheter
heart valves. Structural Heart 2022;6:100010. https://doi.org/10.1016/j.
shj.2022.100010.
25. Arslan F, Gerkens U. Virtual support for remote proctoring in TAVR during COVID-
19. Catheter Cardiovasc Interv 2021;98:E733–6. https://doi.org/10.1002/ccd.29504.
(E-published).
26. Silva JN, Southworth MK, Dalal A, et al. Abstract 15358: Improving visualization
and interaction during transcatheter ablation using an augmented reality system: first-
in-human experience. Circulation 2017;136(suppl1):A15358.
27. Mesko B. The promise of the metaverse in cardiovascular health. Eur Heart J 2022.
https://doi.org/10.1093/eurheartj/ehac231. ehac231.
28. Tailor A, Dubrey S, Das S. Opinions of the ePortfolio and workplace-based assess-
ments: a survey of core medical trainees and their supervisors. Clin Med J R Coll
Physicians London 2014;14:510–6.
29. Peeraer G, Van Humbeeck B, De Leyn P, et al. The development of an electronic
portfolio for postgraduate surgical training in flanders. Acta Chir Belg 2015;115:68–
75.
30. Bauer BS, Nguyen-Phan AL, Ong MK, et al. Cardiology electronic consultations:
efficient and safe but consultant satisfaction is equivocal. J Telemed Telecare
2020;26(6):341–8.
31. Queen Mary University of London. Queen Mary students receive first lecture in the
metaverse. Accessed online: July 2022: https://www.qmul.ac.uk/media/news/2022/
pr/queen-mary-students-receive-first-lecture in-the-metaverse.html
32. Skalidis I, Muller O, CardioVerse Fournier S. The cardiovascular medicine in the era
of Metaverse. Trends Cardiovasc Med 2022;1738:00071–8. https://doi.org/10.1016/j.
tcm.2022..05.004.

14 Curr Probl Cardiol, December 2022